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tv   Hurricanes and Public Health Preparedness Hearing  CSPAN  October 27, 2017 3:11pm-6:03pm EDT

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>> bernie sanders in puerto rico to see hurricane damage and talk to residents. puerto rico governor welcomed the senator and said they discussed the islands urgent needs in the wake of maria and our requests. senator sanders tweeted this picture writing he is there to talk to found a local government representatives about the destruction they are dealing with. congress has approved a package for $36 billion in disaster aid which is been sent to the president. includes hurricane relief. >> next, a house hearing on public health preparedness for hurricane season which comes after three major hurricanes devastated parts of texas, florida, puerto rico and the u.s. virgin islands. the commission of the fda testified about serious concerns he has regarding puerto rico since it's a major hub for drug manufacturers whose facilities have been severely damaged. this is about two and half hours.
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>> i'm going to go ahead and get this straight. thank you, everybody. appreciate it. we are here today to examine the department of health and human services' public health preparedness for and response to the 2017 hurricane season. in the last two months, texas, florida, puerto rico, and the u.s. virgin islands have been devastated by hurricanes. i first want to express our heartfelt sorrow for the millions of americans impacted by these devastating storms and say that all members of this committee on both sides of the aisle stand with those affected by the hurricanes. i would also like to thank dr. burgess and dr. ruiz, both members of this subcommittee, who each recently visited puerto rico to assess the impact these hurricanes have had, and continue to have, on our fellowe americans.
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this committee has been conducting oversight of the federal response to the recent hurricanes since shortly after harvey made landfall in texas. unfortunately, i expect that our work here will continue for years to come. the committee's jurisdiction involves not just the public health issues we will be discussing today, but also rebuilding the electrical grid, addressing environmental cleanup, and restoring telecommunications, to name only a few. the people of puerto rico and the u.s. virgin islands continue to face a long road to recovery and many are living without power and running water. we are joined today bynd representative jenniffer gonzález-colón from puerto rico, someone who knows all too well about the difficult challengess her home is facing. thank you for being here for this important hearing. from coordinating the overall federal health care response, to ensuring that individuals have the medical treatment they need, to protecting the blood and pharmaceutical supply, to
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granting emergency waivers, andr everything in between, hhs has been working tirelessly to provide medical care and services to individuals affected by the storms. the overwhelming majority of health care facilities in the impacted areas went above and treat to protect and those in harm's way. yet, media reports indicate that some health care providers failed in their duty to protect their patients. there was a tragic situation at a nursing home in florida where fourteen residents died after the facility lost its air conditioning and this despite a hospital across the street that never lost power or cooling. the response in puerto rico and the u.s. virgin islands has involved numerous federal agencies, working together with each other and state and local officials. for example, before hurricane maria made landfall in puerto i rico and every day since, hhs, the department of defense, the department of veterans affairs, and the federal emergency management agency, or fema, have been coordinating with local
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emergency response officials to provide medical care and help re-establish the island's health care infrastructure. hhs has worked with puerto rico's department of health to prioritize resources needed for dialysis facilities and has coordinated with fema to help ensure critical supplies are delivered where they are needed. similar efforts are ongoing in the u.s. virgin islands, too. but many questions remain. has the inter-agency response been effective, from the perspective of hhs? are federal policies causing delays in response efforts? are we utilizing our resources in the most efficient and effective ways to help our fellow americans in puerto rico and the u.s. virgin islands in particular? finally, it is critical that we understand the public health challenges ahead. mold formation is likely in nearly all the affected regions. as we have seen after hurricane harvey, there is an increased risk for the spread of infectious disease due to contaminated water. media reports indicate that one month after hurricane maria,
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over one million americans are still without clean, safens drinking water. rebuilding puerto rico and the u.s. virgin islands will take years. the health care systems are inhe dire condition and most of the operational facilities need some degree of assistance. to make matters worse, the electrical grid has been devastated which has significantly hampered recovery efforts. we still don't even know the full extent of the damage, let alone when our fellow citizens will have electricity and running water restored. we are trying to make sure wene are doing everything possible to address the short- and long-term needs of those living in the areas impacted by hurricanes harvey, irma, and maria, especially in the face of the public health threats that have resulted and will continue to result from these storms. i would like to thank the witnesses for testifying heresl today and i look forward to hearing your testimony.f andd without i will know you fie minutes for an opening statement to the ranking member from
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colorado. >> thank you so much, mr. chairman. this 2017 hurricane season has been one of the most damaging on record. hurricane harvey wrote thehe record for the greatest amount of rain recorded from a single tropical storm or hurricane in the united states and inundated houston and south texas with more than 51 inches of rain. hurricane irma became the strongest atlanta hurricane on record for hits the virgin islands of florida -- atlantic -- while the storms have been devastating, hurricane maria's impact on puerto rico and the u.s. virgin islands has been nothing less than catastrophic. mr. chairman, as you said the scope of potential health risk that's caused by this ongoing crisis is the come into focus but it's clearly considerable. over a month after maria hit, the infrastructure of puerto rico in the virgin islands remained decimated. nearly 80% of puerto rico still doesn't have power and hhs
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reported that a substantial number of puerto rico hospitals are either nonoperational or required diesel to runic generators in order just to keep functioning. over a third the puerto rican residents lack reliable access to potable water. contaminated water is also spreading contagious diseases, andr. while i certainly apprecie the effort by volunteers including physicians and nurses volunteering their time with the hhs teams, i and concern for management of hurricane response at a federal level may be hindering response efforts. the federal government i delete probably doesn't have a complete picture of what healthcare challenges exist because, frankly, most of the island of puerto rico lacks adequate communication.n. i think these communities to hold further hearings to address the status of all these vital services that you, mr. chairman, talked about. and even think as time goes on
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we should have field hearings on puerto rico in particular but also the virgin islands, as much of the recovery effort as you so accurately describe involve the jurisdiction of this committee. i can't stress enough how important it is for us to send our staff downca there to investigate this, and how important it is for members to go and investigate this. part of a a group of members that went after hurricane katrina to new orleans to observe the recovery efforts. what we found through years of oversight on this subcommittee was that washington's understanding regarding the situation on thehe ground was vy different and we were able to observe first hand. when we went into the basement of cherry hospital we saw what happened to those records. when we had our field hearing, congressman blackburn was and a bunch of the rest of us, and we saw what it happened to small business people down there in new orleans. you just cannot substitute for
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that. as we begin to think about our publicr response as members of congress, we need to see what we are doing on the ground. mr. chairman, last week president trump said the administration deserves a test for its response to the devastation of hurricane maria. given the fact that most residents lack power, nearly 1,000,000 americans lack access to safe and reliable drinking water, and english reports of new substances living for many, i find that statement to be breathtaking. i hope that our witnesses today are better prepared than that to talk about what's really happening on the ground and what we can do to address this unfolding crisis. i hope it will be the beginning of an ongoing concerted effort to understand what's going on, and i would now like to yield the balance of my time to representative caster who wants to talk appropriate about the health challenges facing her state of florida. >> well, i think ranking member
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degette forgetting the tie. this into what a cattle -- with the catastrophic routine season, and with so many challenges ahead. i want to thank our witnesses who are here today. i want to thank all of my colleagues for holy history. hopefully this is the first of many because this is going to be a very long recovery. after 75 lives lost in texas, 75 lives lost in florida, including 14 related to a nursing home that were completely avoidable, we need to discuss that. we know that we have about 50 deaths in puerto rico so far with the threat of bacterial infections growing. i'm very concerned about puerto rico and the whole interplay between the folks that live there and the u.s. virgin islands and their migration and what that means for the health needs of everyone. on the island, the drinking
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water issueyo is hypocritical. so i look forward to your expert testimony today and theer committees were in the days ahead.d. thank you your yield back. >> gentle video back. recognize a few chairman of the full committee, mr. walden of oregon. >> i think the vice-chairman for holy this hearing. i want to express my deepest sympathy for those of an impacted by these horrible storms, particularly our fellow citizens in puerto rico and the u.s. virgin islands. this committee stands ready to assist in whatever way we can get will continuepp to be diligt in our oversight of the work that the agencies are doing and the needs of the people there. i'm very pleased dr. burgess pictures are health subcommittee has only been toin puerto rico, visit some hospitals to look at health care issues between a with much more work to do and we hope to hear from all of you today about what's out there head, where we've made progress, where there's still problems we need to uncover and think of better solutions. today we examine hhs continue efforts to protect the public
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health in texas, florida, puerto rico and the the u.s. virgin is in the aftermath of the hurricanes. this is theer first in a seriesf hearings on preparedness for and responses to hurricanes, and in also hold weeks will hearings before the energy and environment subcommittees on these matters. as vice-chairman stated this committee will be conducting oversight of the rebuilding of puerto rico and the u.s. virgin islands for years to come. the public health risk typically associate with a natural disasters are varied and include heightened incidence of infectious diseases, diminished access to medical care and long-term mental health trauma, just to name a few of the concerns we all need to be aware of. these risk can be particularly dangerous especially for vulnerable populations such as infants, dialysis patients, individuals who may be immunosuppressed and, of course, the elderly. tragically we saw this in the aftermath of hurricane irma where 14 elderly residents as
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we've heard before of the rehabilitation center of hollywood hills in florida loss the lives of result of heat induced death issues after the air-conditioning system failed during the storm. last week this committee sent a bipartisan letter to the nursing homes owner requesting information on the facilities emergency preparedness plan, inspection history and the steps it took to protect residents after snack conditioning system stopped working. we will do today that while the three major hurricanes to impact the united states in 2017 were distinct and present and continued to present their own unique challenges, many of the protocols that are necessary to conduct an effective public health response are immutable. for example, federal agencies responding to disasters must be able to communicate effectively with each other and with local state and territorial officials to identify any areas of need, cheering individuals have adequate access to basic necessities such as food water and medical supplies.
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as we head into our recovery face it's important we also carefully monitor patient as the transition from hospitals or under medical supervision back to their homes. more than 6% of puerto ricans are now homeless as a result of the devastating hurricanes. we need toe make sure when patients are discharged from hospitals that they are safe places to go and don't end up on the streets and then back into the hospital. following hurricane maria various media reports have calledup into question whether e federal government hasas adequately meeting its obligation to protectel health d welfare of american citizens in puerto rico and virgin islands. on this matter and eager to gain the perspective of our witnesses who have been on the ground, in the areas that have been affected by the most recent hurricanes. making sure americans in need get the assistance they require cannot and should not be a partisan matter. certain agencies are not pulling their weight, we want to know. if there are federal laws and
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policies that are impeding the recovery efforts, we want to know as well. in addition also wanted about any best practices that can be clean fun ongoing recovery effort that can be utilized to the response of any future natural disaster. thanks to you and yourur chancef being on the ground trying to do the best you can in these horrible circumstances. we really need to know the facts what's working, what's not, where they've been shortfalls, what are the lessons learned and where do you need additional help to help our citizens. with that, mr. vice chair, i yield back the balance of my time and look forward to the testimony of eyewitnesses. before i do that, i'd also like to welcome our newest member to the committee, mr. duncan. it was just approved by the house conference this morning, steering committee last night replacing dr. murphy and we are delighted to have you on board to the committee. thanks for being here today. >> thank you, mr. chairman. never denies a ranking member of the full committee mr. pallone of new jersey.
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>> thank you, mr. chairman. thank you for holding this hearing on this critical issue. i hope this hearing is a first of many hurricane related hearings this congress needs to hear further from hhs and other agencies regarding the ongoing response and recovery efforts in all of the affected areas. i would like to take a moment to recognize the federal, state and local responders are working hard to address the many public health issues whicher exist as response and recovery continues in all the areas that were impacted by these three major hurricanes. i know firsthand of the tragic devastation causedl, by such and its natural disasters. in 2012 my district was hit hard by hurricane sandy. i've never seen worse storm damage in are any in my lifetime. many of the storm was a worst-case scenario, homes flooded and businesses lost. the fifth and avs coming up this weekend and we still have a lot of people that are not back in their homes or their businesses. our nation is now experiencing historical levels of destruction
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andd loss of puerto rico and the virgin islands as well as in florida, texas and along the gulf coast in the wake of hurricanes harvey, irma and maria. while no to natural disasters are like, the areas affected by these massive hurricanes have unique needs and challenges. while congress can choose to address the response in florida and texas, we must work to ensure puerto rico and use virgin islands receive the full and immediate support a federal government as they recover. i recognizeze there are a number of ongoing challenges facing the residents of south florida and the gulf coast come much attention it will likely to address the situation in puerto rico and the u.s. virgin islands. the reports coming from these areas indicate hundreds of thousands of americans continue to struggle to meet day-to-day needs. i'm particularly concern that has to reports residents do not have access to food or medicine. asas many as 1 million americans lack access to reliable access to clean water. accounts of the area affected by the storms paint a dire situation that completely doctor dick the awful and rosy stories to come from the president and
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the white house. hurricanes -- including critical damage to electrical grids, telecommunication systems, takingan water systems and transportation infrastructure. virtually all residents of puerto rico and use virgin islands have impacted and he's infrastructure feels great acute public health issues. we've seen the reports of death, dehydration and the desperation as residents of puerto rico and use virgin islands continue to struggle and oppose apoplectic landscape where fundamental help remainshe remains unaddressed. the list of serious needs and challenges is long. many hospitalsma still do not level power. many communities still lack safe drinking water. people have resorted to drinking from questionable water sources. wheree water service has been restored, residents are still unsure if the water is safe. in a briefing to the committee we learned crews going into communities to test for water
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quality were arriving only to find people still lacked adequate food and drinking water. congress must provide ongoing support in the aftermath of these are against restore and rebuild and help our witnesses today one of us understand what needs toim be improved in the response and recovery efforts so that congress can more effectively like assistance and understand impacts on public health, not just today but in the months and years to come. .. states in particular new jersey in my district. you know, my mayors and myelected officials locally are saying is there any kind of help for us because a lot of these people come here and don't have a lotof money and need support, as well. that is also something we need
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to look into. i would like to yield the remainder of my time to mr. green. thank you. our district in houston and harris county, texas was heavily impacted by hurricane harvey. we had at least eight deaths in our district alone. i thank the tireless work of first responders, public health professionals, community members for helping fellow texans during the time of need. i would like to thank my colleagues. there will be much more for not just texas but louisiana, florida, puerto rico the virgin islands and a number of other disasters. the state of texas and cms need to work together to make sure we are taking advantage of every opportunity to help people in need especially when it comes to medicaid. get necessary resources to our local hospital in texas to help uninsured disaster victims. we shifted to recovery in houston and texas gulf coast and are responding to public health concerns related to harvey including spread of moldand spread of disease carrying
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mosquitos. we must be responsive to the environmental impact of harvey including community members, and waist -- watt water. look forward to hearing from the witnesses and work with the public health agencies to dress tease pressing concerns independent our office in houston we do at lot of case work on social yours, vans, you nape it. nowary staff mesh has working with people march we're working through it with ore federal agencies helping to us make sure we can get people back to where they are. >> i yield back my time. >> i yield back as well, mr. chairman. >> thank you, gentlemen. i ask nance constant the members written in opening statement be made part of the record. without objection. >> i ask nance consent that energy and commerce members not
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on the committee be permitted to participate in the hearing. without objection so ordered. mr. duncan has joined the committee and subcommittee put until a formal motion is made on the floor at'll 12:30. we are told we have to treat him as a member over to energy and commerce committee but not yet on the subcommittee on oversight investigations so he will be treats like the members which means he will go last as the newest member of the committee. he would go last anyway. >> we're just -- >> we're just rubbing it in. i did want to let everybody else know what the status was so when they hear a motion later today on the floor, they will understand that is what the parliamentarians told us we need to do. welcome to the committee and
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subcommittee. >> mr. vice-chairman -- >> mr. chairman. >> i assume he knows his other responsibilities for all the committee members, getting us each coffee -- >> we heard actual of these. >> like in scalise was. >> we'll make sure he is aware of those duties, mr. chairman. finally, we welcome honoring and commerce committee members who may show up later, pursuant to house rules, members not on the committee are able to attend our hearings but are not permitted to ask questions. i'd like to introduce our panel of witnesses for the hearing. first we have the assistant secretary for preparedness and response at the department of health and human services. welcome. next, is the honorable scott gottlieb who is commissioner of the u.s. food and drug administration. welcome. then we have mrs. kimberly brand, the principal deputy administeringor fer the centers met care and medicaid services
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and -- welcome. >> host: finally, we have rear admiral steven rid d, the director of the office of public haven't preparedness and response at the center tore disease control good -- control and prevention, we look forward to the opportunity to condition the preparedness for and the responses to the recent hurricanes. now, as a part of the -- what we do we're holding an investigative hearing and it has been the practice of this subcommittee to take testimony under oath. do any of you have objection to testifying under oath? seeing none. the chair then advises you that under the rules of that house and the rule's the exciteee you're entitled to be eye candidate by counsel. do you desire to be accompanied by counsel today? seeing none. in that case if you would please rise and raise your right hand i will swear you in.
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do you swear the testimony you are about to give is the truth, the whole truth, and nothing but the truth? >> hearing affirmative reactions. you're under owing -- under oath. you may enough give a five-minute summary of your written statement. >> good morning, mr. vice-chairman, ranking member and members of the subcommittee is it is a privilege to appear before you to discuss the nation's medical and human being health response to a series of unprecedented and nearly simultaneous category 4 and cat gore 5 hurricanes that hit the u.s. mainland and territories so far this season. hhs -- when i include that it's the diaspora. the cms, fda and cdc and the parter of dhs and dod have push
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the boundary tuesday save lives and sport the communes and people impacted by these major hurricanes. i recognize in regions? puerto rico and virgin island people are still facing dire conditions. saw that for myself in the devastation first hand and can assure you that hhs continues our response of 110% and will work as hard as we can until conditions improve. this is my first time testifying before the committee i'll begin with a brief description on my view of the role of this position. after it was created almost 11 years ago in response to hurricane katrina, by the pandemic preparedness act the objective was to create unity of command by con soul dating hhs, public health and medical preparedness and response functions under one person, i had the privilege or serving as a staff director of the subcommittee that drafted the legs. the mission is my to save --
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simply to save lives and we lead the public health and until response to disasters and public healths in accordens with the national response framework emergency support function number eight. the threats facing the country are more complex and lethal. i i will first provide strong leadership, second, create a national disaster health care system. third, sustain robust and reliable public health security capables and fine finally advance -- hurricanes harvey, irma maria, and nate's simultaneous severity created unique challenges especially in puker no place no perfect, no life was untouched. i would overwhelmedly resilience of citizens make new england
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extraordinariry difficult situation. with the three major hurricanes to dade, ouring extra has been to first, save lives, stableeye the health care system, restore health care services inch puerto rico we are stillened responding. in other areas recovery is underway. herer the men axes taken. in order to save lies, they activated in the national disaster system and deployed more than 2500 person him in from 21 states and hundred of fed employee, including u.s. public health commission core personal to communities impacted. in fact, in each storm we deployed teams even before the hurricanes made landfall so they were ready to respond immediately. we take care of 15,000 patients and 10,700 in puerto rico alone. hhs has sent 43 tons of medical equipment and supplies to the
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affect areas. hhs declared public health emergencies in states and territories before landfall. the pro-actively utilized the empower tool to identify medicare, medicaid beneficiaries in each area who rely on life maintaining and assistive medical equipment and people who rely on dialysis and home health services. we evacuate more than 200 dialysis patients from the u.s. virgin island, for florida and st. and thomas, evacuated dialysis patients. the emergency -- providing free medication. hhs deployed meant health teams and activated behavioral haven't hotlines to aid people coping with the psychological finings of these storms. i'd like to show you a map.
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this illustrates the comprehensive approach providing healthcare and medical services. together with our interagency partners of vp and cd and the puerto rico health department. this is just a fraction of what we ditched i could not speak to all the work that hhs teams and public health service commission core personnel did. they're true american heros who left their families, their medical and clinical practices to render aid, often in arduous circumstances. we're committed to the long period of recovery ahead and also reflect on this experience by conducting comprehensive afteraction review to identify ways to improve our capacity to respond to future human public h emergencies. i'm happy to answer any iowa may have.
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>> thank you. thank you very much. now five minutes for an opening statement. >> thank you, mr. chairman. i appreciate the invitation to discuss the fda's response to hurricanes hear have i, irma and maria, the remarks are fork cutsed on the impact of puerto rico because of the unique role and the enormous magnitude. our commitment is to the people of puerto rico, that's begin the long recovery from the overwhelming devastation. but fda also has a broader mission in puerto rico, a substantial portion of the island's economic base is comprised of facilities that manufacture medical products. this includes many critical medical products. there are currently more than 50 medical device manufacturing plants in puerto rico. they produce more than 1,000 different kinds of devices. to date we're especially focused on 50 types of medical do is manufactured by ten firms in
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puerto rico. these devices are critically important to patient care because they may be life sustaining or police officer supporting or -- life supporting ore the eye handed may be the only manufacturing site for the do ises. we have medically important drugs and biologics that are primarily manufactured on the island. 14 of these products have sole source, meaning manufactured only in puerto rico. to aver shortages we have been working close with by people marks dhs and hhs to troubleshoot challenges related to getting fuel for generators and raw ingredientses as well as logistics to move finished product off the island. our intervention have evolved as the nature of the risk, changed and our response progresses. early on we helped individual firm secure landing right for products that were at risk of being destroyed by flooding
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warehouses and began to help facilities secure diesel fuel, and the last week we have been actively engaged in helping a few facilities that manufacture products critical to the blood supply, secure small quantities of -- these challengesser being solved through better logisticses and no longer require active intervention. that's the good news. we have processes in place now that are helping guarantee supply of diesel fuel, raw manufacturing ingredients and medical gases and other critical components. but other challenge will arise. one that concerns us the most is in long-term power. many generators weren't mention to fungs for months on expend a lot of facilities cannot return to full protection on generateyear power alone. most are producing at anywhere from 20% to 70% of normal capacity based on our informal survey. they won't be able to resume
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full production until they are back on the power grid and if they don't return to the grid we could face mountain well potential shortageses in these shifts more manufacturing off the island. with my remarks i'd like to give you a perspective on the human fact you're we're seeing every day. the we see residents taking often heretic steps to keep slies slowing and where the firms that mr. these items are taking their own extraordinary steps as good corporate citizens to support these efforts. if we're going avert major product shortams it well be as a consequence of these efforts and want to take note of these activities and support them. first and for most, i want to take most of the americans who's in puerto rico. this medical product industry 90,000 puerto puerto ricans. if we avert the shortages it is because of our fellow citizen who returned to their critical
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posts. we owe them all an enormous debt of gratitude. want to take measure of the good corporation operate citizenship that fda has been witness development even as we watched some companies take extraordinary efforts to maintain their production, they took equivalent steps to assist workers. many facilities are serve agent disaster relief stations and they're helping distribute fema aid to the outlying towns, companies that are distributing gasoline to employees and general relief items and using their cav fears to feed employee and families. one drug company tolds they shipped thousands of generators to the island for distribution to employees as part of hundreds of tons of relief aid. we know of companies that created programs to help employees rebuild homes and resume their lives. some of these programs including
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cash grant match donations they accept from employees across the globe as would way to help puerto rico employees rebuilt their homes. want to recognize these efforts here's will be a could i part of helping puerto rico recover. want to recognize the people of puerto rico the few did to the public haven't mission. we owe the island'ss or steadfast and long-term commit tom a full row. thanks a lot. >> i thank you for your testimony, and now i recognize miss brandt for five minute opening statement. >> thank you. thank you for the opportunity to discuss efforts by the centers for medicare medicaid services to respond to the recent hurricanes. cms plays an gig ball role in emergency response. i have also 20 years of experience working on medicare and medicaid issues and i was
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surprise ted department of -- depth and breadth of the involvement. we take this serious as evidenced -- the we're saying on the ground efforts and gaining valuable input from patients, providers and local officials empeople think of cms as a payer, reimbursing for beneficiaries and secondly as regulatorror, overseeing and enforcing standards by care delivered by providers and suppliers. why we do not directly provide care we do have a direct impact on the care they receive, and the last several weeks allowed to show the important role we can play. one of our most valuable emergency response tools this able to waive or modify certain program requirements which cms can be left to the president to declare a major disaster and the hhs declares public health
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emergency. cms ising you the full authority to ensure by-rid have the access to the care they need by providing flexibility medicare and medicaid providers to deliver high quality care to those who need it when and where they need it. for example year, waiver's allow medicare providers to move patients between facilities and administer care and toed and died enrollment. we have approved nearly 100 glaze total across the area. last month i joined administrative on a vote to houston, texas, and special to several impeaked, including bis and i providers who -- we want beneficiaries and providers to focus on their immediate needs to provide urgent care without worrying about reimbursement policy and we heard during our visit what a difference those flexibilities make. that is why cms is taking an active listening approach and meeting and talking with stakeholder in all of the areas
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ongoing to make sure we understand their needs and able to meet them. one of the administrators top priorities has been to provide access to necessary care for one of the most visual beneficiary groups, dialysis patients, during the challenges circumstances. one of the ways have done this is using our authority to temporarily designate dialysis facilities licensed in locations impact beside the hurricanes but that are nor yet certified to serve as special purpose renal dialysis centers. in puerto rico and the u.s. virgin island cms has been working close whiff the kidney community emergency response program and the end stage renal disease network. here are two examples of our combined efforts. under the direction of one our
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cms commission core members we're working to daily track the operational status of dialysis facilities in puerto rico and their status we respect to fuel, water and other supplies and developing delivery schedules. cms partner evidence with sell of oured and local partners to rend -- support for 120 dialysis patients evacuated from the u.s. virgin islands to atlanta when conditions no-no longer -- no-no longer safe. we worked to great and medically assess each patient as they arrived. unfortunate the recent event withs be n lost public health emergency. it is essential sewn sure patient state. fema is requiring all medicare' medicaid facilities to comply with basic health and safety
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requirements including emergency preparedness standards which we updated last fall. they clue more comprehensive approach to emergency planning and requiring facilities to address location specific handers and we require facility ies to meet emergency training standards for staff and contacting person. while much has been done there's still much to be done, perksly -- particularly puerto rico witch must think creatively. we appreciate the subcommittee's interest in these efforts and look forward to working with you through the recovery process. >> thank you very much flint. your testimony. now, recognize rear admiral redd for five minutes for an openings statement. good morning, vice-chairman
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griffith, ranking member and distinguished members of the subcommittee, i am rear admiral steven redd, director of the centers to disease control and prevention office for public health preparedness. spent the opportunity to be here today to discuss the efforts and activities in response to the 2017 hurricanes. to address the impact of these hurricanes, cdc provided public health support to the coordinated federal, state, local, territorial and tribal responses. the focus of cdcs efforts have been in epidemiology and health surveillance, laboratory support, environmental and obviousal health, and -- occupational and health and health communications. on august 30, 2017, we activated our emergency separation snore coordinate our response -- coordinate our response to hurricane harvey and expanded that activation to include hurricanes mayor and maria. since the end of august cdc has
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had approximately 500 staff members supporting the response. additionally we have deployed over 70 staff to the affected areas to provide on the ground support including 34 to puerto rico and 12 to the u.s. virgin islands. to address immediate health concerns, kdc deployed -- each federal medical station can accommodate up to 250 patients, and includes a cache of medical supplies and equipment. hhs deploys medical teams to staff these facilities and cdc has deployed six of these to puerto rico, four to texas, and two to florida. cdc has used surveillance to monitor health related data that may signal a disease outbreak. our national drone program has
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-- works closely with the american red cross to monitor data on shelters of surveillance during the response has indicated elevations in carbon monoxide poisoning and this has led to increased messaging to prevent this condition and guidance on the safe operation of generators. identifying and controlling public health diseases -- diseases of public health insurance in puerto rico and the u.s. virgin island or a priority. the puerto rico department of health, sustained significant damage during hurricane maria, including taj to their laboratories. these will beer toes are not able to conduct any public health tests. they're not able to confirm diagnoses of infectious or environmental diseases. cdc is working with the puerto rico pa department of health and fema to get the laboratories
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back in operation. in the meantime we arranged for packaging and shipment of clinical specimens of suspected priority infectious diveses such as tbs tb, rain by, influence sharks salmonella for the u.s. mainland for testing the first shot recently arrived in atlanta. let me touch briefly on a few other components of our response. we provided tech income cal assistance to affect areas to address health issues sun as food safety, water issues, including sewage, we have provided guidance on injury prevention from debris and drowning. we have helped with shelter assessments. we have provided guidance regarding the safety of responders. and we have developed and disseminated key public health messages to individuals in the affected areas. cdc recognizes that the full recovery from the recent
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hurricanes will take time, particularly in puerto rico and the virgin islands where the damage has been extensive. we're here to continue to provide that support. thank you again for the opportunity to appear before you discuss our response and recovery efforts and i'd be glad to answer any questions you might have. >> thank you all very much for your testimony, and i will now begin questioning by recognizing chairman of the full committee, chairman walden, for five minutes. >> thank you, mr. vice-chairman and thank you for your testimony and the work that the people you represent are doing in these terrible tragedies and we all know there's more to be fun it's hard -- the aftermath to fit right and we sure appreciate what you are doing. on behalf of the at-large resident commissioner from puerto rico, thank you for joining us. you're not allowed to ask questions but i can on your
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behalf so i appreciate your committing some of these because i think they're important to get ton the record. doctor, i'm going to start with you. puerto rico remains in the response mode of saving lives and stabilizing healthcare services. what major milestones must be completed to progress from the response phase to the recovery phase? if you can just be fairly brief on that because i have a couple others. >> i think it's been highlight by members of the committee. the power situation ton the island does represent a significant limitation. right now we have 60% of these 67 hospitals that are on the power grid, and have reliable power, but there are 36% total of 24 that still do not. and that's an important benchmark in terms of the ability. the -- >> timeline is to get them the power they need? >> i really wouldn't be in a position to answer that elm thursday army corps of engineers is trying to move as aggressively as fob do that ump
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they heave prioritize hospitals, health clinics and dialysis centers to re-electrify with the grid. is is to get them up as quickly as automatically possible. the other part of this is the knowing about the operational status of the hospitals because some of them have physical damage to ensure they can basically resume full functionality. it is again working closely with fema and with the army corps of engineers we performed assessments of the hospitals to identify which ones need physical repair, and then there are also issues that relate to supply chain restoration can things like oxygen, which is a matter of topical interest here. >> thank you. rear admiral, thank you for being here again for the work you're doing. how is the cdc branch in puerto rico being utilized during the recovery effort and then i have one moore for you.
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>> the branch was affected just like every other location in puerto rico. as of october 10th the laboratory is back in operation. it's functioning at low level under generator power right now, so i think it's more in the affected than in the response zone of the efforts at this opinion. >> when do you think it might be up to full operation? >> i think some of the issued that the doctor raised would be germane to the full activation and operation of the branch lab as well. >> particularly concerning is the college to puerto rico, department of health labs, to date the labs are not able to conflict public health testing, including the able to confirm editions of inefficiency and environmental diseases. what wilt take them to get up and running and in their absences what inning the opening this could lab work? >> so, the restoring power is the first step.
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there is work with army corps to identify the generator capacity needed to bring the laboratories up back to power. there will be a second level of effort to determine what equipment can be salvaged and what equipment can't be salvage. we don't know the results of the assessment until the power is back so going to be some time. >> you don't have timeline on sister. >> i think for generators we're talking weeks at the most. >> but they'll be running on generators or before. >> yes, maybe less than that. can't say about the back on the grid but there should be power the labs win a relatively short period of time. in me meantime, we're working with the department of health in puerto rico to ship specimens to atlanta for testing and that's where the first shipment cases has been shipped. >> are you comfortable, perhaps it's you and others on the
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panel -- with that kind of arrangement to do the lab testing? is that quick enough, adequate enough? >> it's certainly not optimal. it's the best we can do at this point in time. think what we need is to be where those tests can be done in puerto rico and having the lab back up to full speed. >> if it's going to be weeks before that can happen there is a temporary sort of lab that would be flown? there? iwe haved a discussion on that. think in general, the -- the feeling is that the getting specimens to atlanta for testing is going to be actually -- not going to be very, very prolonged per of time. this is a temporaryize measure. not optic mall -- >> but work? >> yes. >> my time is expired. thank you for thing hearing and thank youor your testimony. >> thank you very much, mr. chairman. now recognize the ranking member of the subcommittee.
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>> thank you so much, mr. vice-chairman. i just want to remind the panel, you all know very well, it's now been over a month since maria hit both the u.s. virgin island and puerto rico, and even now there was just an article in the anytime nims today which is entitled life going back in time. puerto ricoans survival skills to use. it is a very powerful article that talks about how people still don't have power, still eating canned foods. elderly people are afraid to go outside because of gangs, and what it talks about is the way everybody is helping themselves, is the neighbors are bonding together, and there's a fellow, the director of a local nonprofit said most of the aid
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to neighborhoods which appears to be in san juan, not in the remote mountains, had received from private citizens and deliberates, quote, the government has not arrived here. so, having been, as i mentionedded in my opening remarks, having been on this subcommittee win we investigated katrina, it's wonderful to reflect back on what we have done, but it's more important to think about, a., how quickly we can do more, and, b., what we can do to improve our efforts in the future. i just want to remind that to everybody, listening to this testimony, you'd think that everything was just swell and i hope none of you intended to intimate that. know we'll have a lot of questions about that but commissioner gottlieb, i want to hone in with you about your testimony because as you said, there are a lot of drugs and devices that are produced in puerto rico. there's 13 of emthat are drugs
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that are only produced in puerto rico. is that correct? >> there's more than 13. probably somewhere in the nature of 40 sole source drugs and only 14 we think are critical insofar as they're medically important and couldn't find a therapeutical alternative so about 14. >> and most of those plants where those drugs are being manufactured are relying on generators. ... what do you mean by sustained period of time? some of them are very hard and so i don't want to say there
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aren't some that couldn't operate indefinitely on generators, but that is the exception. most will not be able to operate for a sustained. of time. if we get into the first quarter of next year end these facilities are back on the grid, we will have some concerns. we are trying to think now how we can work with ourgr partners at hhs and the army corps of engineers to prioritize a handful that are critical. >> the reason you will have concerns is sort of twofold. number one, generators don't produce the kind of energy they need to produce for these products. >> that's right. >> and number two, even if you can use it, it's going to be a reduced supply. >> that's right. in most cases, i know of one firm that is producing at one 100% output right now, but they have dialback certain portions of their facility. in most cases, these facilities can't operate at
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one 100% production on the generators and they certainly can't operate 100%. >> the other point is that the generators themselves are going to start breaking down.t >> that's right. they're not meant to operate these plants. images ask you quickly, on friday, you released a statement that said the fda's monitoring about 50 types of medical devicespe manufactured in puerto rico that are critically important to patient care, including everything from insulin pumps and pacemakers. is this the same kind of problem that we are seeing with the drug's manufacturer. >> same challenge. these are 50 devices that we aree monitoring, manufactured by ten different firms. it's a similar challenge. in some cases the device manufacturing is more energy dependent and the facilities themselves need a more reliable slope from the grid. even as these facilities get put back on the grid, if the grid is unreliable, they might prefer to stay on the generator power for a longer time period.
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many of them will also want dual feeds off the grid so it could be a while before some of these facilities can get the kind of connection to the grid that they need. >> mr. chairman, let me justndhi say, if anyone has any concerns this is impacting all-american families, my daughter who is a type one diabetic just got a letter from medtronic last week saying her new insulin pump was not going to arrive because of the problems we are having in puerto rico. it is impacting everybody, every american, not just americans in the u.s. virgin islands and puerto rico. i would like to ask unanimous consent to put that new york times article into the record. >> without objection. i now recognize ad. vice-chairman, mr. burton of texas for five minutes. >> thank you, mr. chairman. i want to extend my personal welcome to our newest member, mr. duncan. he is an outstanding member of the republican baseball team that i manage. i am sure he will do just as good if not a better job on
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the committee. we are glad to have you. we look forward to a bright future with you. mr. chairman, and appreciate this hearing. another primary focus is puerto rico and the virgin islands, but we had a hurricane in texas too. we are a little bit more developed as a state so our ability to endure it was possibly somewhat stronger. having said that, there is still issues in texas. the first question will be to mr. red, there are lots, in a normal year, there is a lot of mosquitoes in the houston area. given the amount of water that was sustained and we still haven't had a freeze, so we still have that issue, what
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cooperation, if any, have you and yourif agency had on helping minimize that problem in the houston area specifically and the gulf coast generally. >> we operate as part of the combined federal response. we've worked with dod through the female managed response system to provide advice on what kind of mosquito control efforts would be most appropriatee and we worked through that system. we don't do spring ourselves, but we provide that expertise on mosquitoes. >> as far as you know there's not an issue of not enough pesticide, excuse me insecticide.
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>> the type of mosquitoes that follow a hurricane aren't typically once that transmit disease, and there's pretty much a standard approach to that with cdc providing technical advice, dod providing the equipment and actually doing the spring. that happens in consultation with the locals mosquito control district. >> similar question, this would be to the doctor. >> lots of medicare patients and the texas gulf coast area and many of them have had to go to hospitals for treatment. under current regulations, do they have the authority to reimburse these hospitals for these emergency treatment of medicare treat patients? >> since we have a
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representative from cmf, i will ask misprint to respond to that. >> that's my fault. i should have directed that to her. >> no problem sir. thank you. we are currently working with state officials to work with them on the uncompensated care issues and develop a plan so we can make sure to appropriately reimburse those providers. >> is there anything the state of texas needs to e re supply cms to get that put together fairly quickly. >> currently we are working with state officials to c w do a multistate 1115 waiver to allow them to request federal matching dollars for care pool. we are working with the state and hope to correct that in the foreseeable future. >> i'm a cochairman of the harvey task force.
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my democrat and cochairman is henry. if there's anything that delegation needs to do to assist in that, if you would let his office or my office no , we will make sure you get whatever information you want. >> we will certainly do so. >> with that, i yield back. >> the chairman yields back. i now recognize the chairman for five minutes. >> thank you. at a recent press event, president trump said he would give his administration a ten on its response efforts in puerto rico. i have to be honest with you, from what i hear from my mirrors and counsel people -- and mayors, i would give a best of the two on a scale of one to ten. my concern is, as i've expressed a little bit in my opening statement, this isn't only an issue of what's happening on the island but
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also the people who are coming to the united states who have needs. i don't think they would be here if they were able to stand puerto rico. this is an example, i'm looking at the home news which is one of my towns in my district and it says when the puerto rican governor visited with president donald trump on thursday to ask for aid, he said without immediately help to rebuild the island there would be a mass exodus to the united states.an then they said the number of puerto ricans who will move will likely spike once people determine they can't stay on the island longer if power, money and water do not improve. i would like people to come here if they can't get basic necessities on the island, but this, the fact that the president would call this a
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ten is absurd in my opinion. let me start with the doctor. recent reports indicate that 80% of americans on the island are without electricity. one reported his city's ambulance had responded to at least four callser and patients have died. they have had to take in patients where generators have failed. when we had sandy, i think our power was out for two weeks. it was impossible. i can imagine going for months without power. lack of reliable electricity. [inaudible] would you agree withty that. >> it's affected the whole society. >> i appreciate your honest response. last friday cnn reported that 35%ck of residents still lack
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access to running water. without adequate drinking water, they perfected the populations that run gastrointestinal or related diseases. sandy, i only when a couple days without a shower and i couldn't deal with it. the man asked the doctor, this poses a major health concern? >> yes or. >> this morning, and article going back in time previously reported that the breakdown in electricity and telecommunications systems had pushed puerto rico back a century or so ago. yesterday the fcc reported that 70% are still out of service.e that's for their celll phones. you can't even address emergencies if you can't communicate.
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dr. would you agree a functioning communication system is also an essential component. >> we've done a lot to ensure we have positive medications on the island, either by radio, self-medication are landmine. we worked hard to maintain, we've deployed national guardsmen when there was no cell service on the island to ensure we could keep positive contact. your point about the generator, i think that's fair but quite frankly, we've created a whole system to tha that.address impact, when i was there the first week after thehe storm, one of the hospitals were one of our teams was located lost generator power. they had several patients in intensive care who were having surgery at the time, and we were able to transfer them safely without loss of life, not only to our shelters where
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ourr teams were, but transport them with ambulances and helicopters a. too that point, we've gone to extraordinary steps to basically help. >> i appreciate that. let me just one thing before the time runs out for the president said it was a ten. i gave the two. would you give me a number between one and ten. >> i'm not in the business give you marks but we are working 110%, even today to help those people, help our fellow americans. >> i appreciate that. >> thank you so much. we now recognize the gentle of indiana, ms. brooks, for five minutes for questions. >> you to all of our panel members for being here. i want to talk a little bit more about the disaster medical system you've described and, i know you've only been on the job for ajo few months. how many months have you been on the job. >> 60 days. >> a tough 60 days.
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obviously, you were very familiar with the organization prior to becoming in charge of it. are there reforms to the national disaster medical system that are already considering or other challenges you've already faced whether it'ser deployment or the number of resources or authoritiesav you have. what are they? >> all of the above. i think this is of extraordinary nature and to go down into the devastation is prettyau extraordinary. i've made five combat tours in iraq and i've never seen anything like that seen in puerto rico. number two, it would simulate the nuclear destruction without fire or radiation part.
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we were stretched in terms of our capability to apply. i give a lot of credit to the physicians and nurses and paramedics and pharmacists who basically deployed on numerous occasions. we had people from colorado who were at harvey, irma and nowma maria. the answer is we probably need to do some creative thinking. we worked very well with the va in puerto rico, we probably need to work better with dod but i think there are a lot of things we need to do to remove dependencies that require us to basically not have transportation and have a larger supplyy capability and move faster and better.
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we have extranet people doing extraordinary things. we probably don't give them resources.it or >> with respect to the authorities, has it been clear who is actually in charge? do their need to be additional operational capabilities provided to them. >> i think that is something we will look at after action. i think we've done pretty well but i think we can do better. i'd like to work with your staff to identify those things and remove those dependencies. >> thank you. misprint, i have some questions provided by
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representative gonzales. apparently, prior to the hurricane, retention of medical personnel has been a challenge. according to my colleague, almost a doctorate they would leave the island not be practicing their own affected specialist left in the territory. how is that impacting the recovery efforts? another individual reported having trouble getting back on the island to help her people. what is cms doing relative to the physician issue. >> thank you for the question. that is something they're very concerned about and very aware of. in terms of the retention
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issue with been working with the department of health on the island and seeing what we can do administratively to be able to lift any requirements to make it easier for people island to workd with them to see if there are programs that we have that would provide incentives for physicians and othernd medical personnel on the island but ultimately that is a decision by the island, in terms of allowing people to come in to assist with the effort on the island, especially in wake of what has happened, we have made waves many regulations and authorities that would have limited out-of-state or out of territory providers to come in and provide care and work with the department of health on the island to see what else we canrt do to ensure they have as much access to as many personnel as we can get them. >> thank you for that flexibility. my time is up. i yield back. >> we think the gentle lady. we now recognize the gentle lady of florida for five minutes for questions. >> thank you.om over a month later, folks in
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florida and across the country are still reeling from the avoidable death in nursing facilities in florida. there are now criminal cases, civilt cases, we are trying to figure out why florida's governor has deleted voicemails that came directly to his cell phone, but there's an important back story here. in 2005, after hurricane katrina and the 215 death nursing homes, cms determined that many nursing homes are not prepared and they went in to try to determine there would be an alternative powerful power source available. i understand it will be november when it will become
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effective. why has it taken so long, and are you confident it will do what we needed to do? >> let me state that we share everyone's concern about the tragedy that happened at hollywood hills. it should not have occurred. our first and ultimate priority is ensuring we have patient safety and patient protection. with the respect to the rule, it went into a affect last year. we will begin serving against it this november.
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however, it is something that we think goes a long way toward addressing a lot of concerns i have been raised by hollywoodhiai hills. we want to continue to look at it to see if we could do more. we must ensure there is a disaster recovery plan and that there are supplies like backups and generators and to be able to maintain the temperature between 71 and 81 degrees. we are also working to make sure that staff are trained so they know what to do. based on the reports i read, several of theed failings were that personnel did not respond to the emergency preparedness plan and they were not adequately trained were able to take steps accordingly.
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those are things we will be working with. i encourage you to do that. health services provided under medicaid plays a critical role in how quickly families are able to recover from natural disasters. following katrina, the bush administration took a number of access to easemi barriers through medicaid. for example, cms allowed for a temporary expansion of medicaid eligibility in affected areas. congress, and the deficit reduction act, acted to ensure that states were fully reimbursed that one 100%. does cms intend to take similar action in response to harvey, irma andon maria? what exactly and what
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difference will there be between puerto rico and the u.s. virgin islands and the states and the mainland. >> there's multiple parts to the question so withe respect to the eligibility requirements we have already put in place the same flexibilities that were in place for katrina to allow it to people have the flexibilityl. if they don't have the appropriate documentation or if it was lost in the floods of the wind or any of the other natural disastersrs n, so that is already taking place. with respect to the uncompensated care pools you mentioned, that is something we are working with the office of management and budget to work with congress on because that is something only congress can address from offending perspective. and then, with respect to how the states are treated differently than the territories, with respect to that, we have basically been holding them all, having the same amount of waivers and flexibilitieser across the board, but one of the things we are watching is the number of people leaving puerto rico and going to the states and making sure that we are working with the statesre t to make sure those dates are
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compensated for the care they're providing to those of actually. >> i look forward to working with you. take you to the panel. >> thank you very much. we now recognize gentleman from michigan, mr. walberg. five minutes. >> thank you, mr. chairman and things to the panel for being here. i have a few questions as well that the congresswoman has asked totoe address. the important that i think they address some concerns now as well as future consideration. would it be beneficial to postpone the medicare advantage a moment. two january 2018? i asked this of misprint. given that 80% of the population is without electricity and toilet medications remains largely down throughout the island. what would be your answer to that? working tobeen establish an enrollment.
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so they have flexibility because we recognize that many of them may have trouble meeting the current moment. >> soe that is viable. >> yes. >> how are you ensuring puerto rico has the medicine it needs? >> i would defer to the doctor because that's more of a supply-chain issue. we simply pay for the prescriptionon. >> there been several approaches to basically address medicines on the island. probably the most important thing we did with the principal medicalwi supply on the island was provide fuel to maintain their generators so they could keep refrigerated products and maintain their supply chain as well as make sure there are trucks to deliver it. we have also been monitoring the availability or the functionality of pharmacies. there are over 700 pharmacies on the island .92% to 93% of them are open at the present time. we have worked with mainland
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distributors of temperature sensitiveto items to ensure they can basically push in their, insulin is a very big one that we worked with people as wellis as with major transporters of materials to make sure those issues are prioritized. i also turn to the doctor because his agency has been very influential as well working with mainland suppliers to bring in products but we been working on a variety of different things. we have cash they take and provide pharmaceutical resupply to hospitals and patients. we've done tailgate medicinee where we have actually gone into areas that are rule, remote and have been cut off. we've done so by helicopter and all-terrain vehicles to deliver medicines to people who need them. as we've gone to a variety of different lengths, some very straightforward, and some
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pretty exotic to do so, but we try to meet whatever need is out there. >> commissioner, could we could you respond to that. >> the point that i would add to the comments is that there is a number of facilities that manufacture predominantly for the island of puerto rico on puerto rico. we have prioritize those of facilities. in terms of how we thought about our mission, we have prioritize manufacturers who supply critical products to the people of puerto rico. early on, we worked to prioritize getting those back online. >> one more question, it has been reported that medical production continues to be a challenge in puerto rico. too do please update thehe
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committee both on the actions the fda is taking to ensure that all patients that require oxygen are able to receive it as well as thel agency's actions to guide against potential shortage of medical oxygen. >> we have worked with our partners at hhs. i will defer to them on this because they've played a more active role with these facilities.. >> so there are two principal suppliers of oxygen on the island. both off them are operational on the grid right now. there was a smaller supplier and then a very large supply of oxygen and they have both suffered loss of electricity in the immediate aftermath of the storm. again, barging in, but oxygen is not the only gas that's needed. co2, nitrogen, argon are all medical gases that are needed by manufacturers as well as the clinics out there. we basically have been trying to move what we could which is
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floating around the island on the westernon side. it can produce oxygen and so we were actually filling cylinders of oxygen using the comforts capability to basically provide that as well as bring in liquid oxygen generators so we can provide temporary filling. right now, i think we are on the right side of the oxygen problem. both facilities are operational and i think the supply should be sufficient as we go over time. just to build on that they've been able to secure the supply they need and in a few instances, historically, we've had to prioritize getting some of those onto the island or from the island, but in most cases they are stored outside
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the island and we've moved past that for the most part. they are getting the gases they need for now. >> thank you, i yield back. the gentleman recognizes the gentleman from california for five minutes.. >> thank you, mr. chairman for holding this hearing. by way of background, i am a board certified emergency physician. i was trained on humanitarian disaster aid including the international committee of the red cross and i was a first responder after the earthquake in haiti and the medical director for the largest internal displaced camp in all of port-au-prince after that earthquake and worked hand-in-hand with the 32nd airborne. i've seen the challenges that arise in the middle of a humanitarian crisis and the importance of having clarity and a plan and clarity and coordinating among agencies, local and government officials and ngos in the field.
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while i am grateful we are having a hearing on this issue with hhs, we need a more accurate view of what is happening in puerto rico with all stakeholders from all levels of government and all the different agencies, including clinical workers and ngos and people who are actually in the field. two weeks ago i flew down to puerto rico to see the conditions for myself and do a needs assessment based on my training and my experience. i'm here to report to you what i saw and give you some helpful recommendations.co one, the people of puerto rico are very hard-working, humble people with respect for themselves and their dignity, and they are doing every thing possible to help one another get the job done and take care of one another. number two, the people who work in your agencies are giving 110%. i have to giveve kudos to teams i spoke too. they've done fabulous jobs and
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are doing an amazing job. i went further into the community and did not stay in san juan and listen just to leaders. i listened pediatricians on the ground, shelter coordinators, patients were on the groundditien t, and what i n tell you, these are the problem. one, there is a lack of clarity of leadership. i'm talking to high-level officials from all the different agencies and i'm not going to mention names, but the folks in the puerto rican governments are saying fema is running the show. people at fema are t saying where we are taking orders from the puerto rican government. i talked to people from hhs and they are saying we don't thank you very much with the dod. there is a lack of clarity with who is actually running the show in puerto rico. two, there is a lack of coordination. you are not to get the full picture if you stay in san juan. you're not going to get the full picture if your leadership, and peopl' making decision are based in san juan
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at a convention center with air-conditioning and food and drink and everything.g. you've got to get your butt out of san juan, into the remote area to talk to people and see firsthand. the other thing is, the problem is there is a lack of priority and clarity in the metric that you are using, and what you're telling the american people what your efforts are. what does it mean when you say bottles and food were delivered to all miss minutes appellees so people get a sense you're doing your job when in fact we should be talking about is capacity. capacity for food supply chain, capacity for electrical grid repair. capacity to deal with the need. all of you have mentioned numbers and the number of clinics and people on the groun ground, but what you haven't mentioned is the denominator. the actual need. of your hospital capacity, what is the capacity to the overall needs of the people on the ground.
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this is my one recommendation, and i strongly agree you will be able to better handle the situation on the ground with a lot more sense of urgency and real-time flexibility. yes, keep your command center in san juan, but create command posts on the ground with representatives from hhs, the army corps of engineers, dod, department of housing. the department of homeland security with fema, the representatives from the local grid, federal and state counterpart including ngos and local mayors so they can have daily briefing and problem solving as theyy arise on the ground. let me give you an example. i went to one clinic. they had a generator fixed by fema. the local quit clinic didn't know when that generator that fema installed went down. they were without power for today's turning patients away. they didn't have a number toey call to determine whether w they
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were on that i went to it temporary shelter at a local school and one of the communities, they were going to close c their doors on october 23 when school starts. the mothers telling me their children needed bottled water. there's a department of defense army guy thing we have a caseload of bottles. can we get authority to move them down. hell yes. so, having command post on the ground and every municipality where local mayors and everyone can hold each other accountable to address needs and real-time action and cut the mother may i and get the food and transportation and address problems in real time is what the people of puerto rico need.d. there is a lack of sense of urgency when we talk about these issues. your folks on the ground are doing an incredible job, but the urgency to meet the needs of 3.4 million people, water, food supply chain, electrical
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grid, those are your top three priorities to prevent unnecessary loss of life of americans on the island. i feel very passionate about this because i took care of a woman who, in front of me in a shelter had a shor a seizure. i protected her airway. i tried to get her to emergency care. there was note oxygen, there is no medicine at this temporary place. we have to do a better job on the ground coordinating with different agencies so we can save more tmpto lives and do all your mandates are about to do. i think the people on the ground doing incredible work and i look forward to working with you more to make sure that we have command posts out in the field. >> we appreciate your passion and agree we probably are get down there and get out and see things and we appreciate you having visited down there we look forward to yourg bo input s the committee works further on these issues. we now turn to the strictest
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tello of pennsylvania for five minutes for questions. >> think mr. chairman. in your written testimony, you mention puerto rico faced public health and public health infrastructure challenges prior to hurricane maria's arrival which exacerbated the hurricanes affect. could you describe what some of these challenges were, and how they adversely impacted the public health response effort. >> sir, i'm just going to make a comment to remind you that they sustained to hurricanes, not one. on the northern side of the island where a lot of the public health infrastructure is, remember there were two events on puerto rico, not one. that was the challenge from the get-go. >> i think the nature of the event is what stress the
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system so much that it was soss destructive. i think also some of the things that have been talked about earlier and the overall weaning of the number of providers is really a risk factor for damage to the public health system. saying the infrastructure was sufficient and even if the infrastructure was more improved than the condition it wasn't it when the matter because the storm was so ever stating. >> ist think whatever amount of destruction you sustain it's changed from what you had before. a stronger system before an event would mean you'd have a stronger system before an -- after the event. >> i think that's what i'm trying to say. what kind of infrastructure
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improvements are necessary to make moving forward so maybe a storm of lesser destructive magnitude, but nevertheless damaging, there be a better response, the ability to have a better response because better infrastructure was in place. >> short. i think some of the instances of damages the laboratory, if there's a generator capability that can be set up more quickly. [inaudible]
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can you elaborate on how some of the lessons learned from previous national disasters such as hurricane katrina improved hhs response to the recent series of storms? >> thank you, sir. >> i think one of the things from katrina was basically unityy of effort to capitalize on the comments earlier, one of the things that created it was the idea of a fragmented medical response so and so while i can't dispute the issues of field command post, i can say certainly and with great authority that throughout our efforts we were trying to work very closely, not only with the department of health and puerto rico which kind of sets the requirements for what they need that we try to service and satisfy, but working across, not only department of health and human services as we show her here our solidarity with cdc, fda and cmf and other entities within hhs but across the federal government with da and dod.
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the uniqueness of that is displayed in porter rico that wasn't displayed in katrina where you had veteran affairs clinics and hospitals basically providing for not only veterans and their families which is not typical, but also the general population. in doing so, with combined demand assistance with our national disaster medical service teams. that just gives you a flavor of that. i think the other part of it is the lessons learned is that we saw in texas and we saw in florida that there are hospital preparedness grants. they help hospitals prepare. first it was for hospitals in the no's coalitions of hospitals. basically they were able to tydemonstrate communications and capabilities within those coalitions that made them more sufficient and resilient to these effects. a given example, one in particular which was pretty extraordinaryen in houston
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which, if you recall back several years ago, they were very bad floods in 2008. it flooded out a lot of the hospital h infrastructure in downtown houston. they took hospital preparedness grants that you authorized and appropriated against basically ensure that they could not only withstand flooding but also a whole set of procedures and communication they could continue operations despite hurricanes and floods now is not only the case in houston but in beaumont texas where some of those same grants easily made sure the hospital personnel had waiters so they could go recover patients. there are a lot of great lessons learned inos this one thing about the capacity of americans to not only help but volunteer as we've been witnessing in porter rico right now, but the idea is we will do a little bit more
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formal one. >> such a thorough response that you actually answer the question that i didn't get to ask as part of that question. can i ask you to supplement any additional lessons learned, not an admission that he didn't do anything right but sort of consistent with the comments relative to what moving forward canttormm be donn order to improve the next time a tragedy like this might occur so we are better prepared. we all want to be better. >> thank you gentlemen. we now recognize the lady from illinois for five minutes. >> thank you very much. 14 people died at the rehabilitation's center in hollywood hills inin florida when it lost power, and overheatedte from september 11 to september 13. as seniors went into distress,
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providestruggled to 911 with basic information, including the address. i was also reported that the same facility had previously laid off hundreds of workers, including nurses. the nursing home stated it employs full-time and part-time employees but did not state if the nurse was present when those patients went into cardiac arrest. did cms find, and you could give me yes or no, simple questions, did cms find that there was a nurse on site at this nursing facility from the h of september through the 13th? >> we have a full report on which i would be glad to get you. i don't know the specifics of it. there was specifically a nurse, i can't -- >> is a nurse required to be present in a nursing home. nsi >> it requires clinical staff to be present. >> are there require
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requirement for nursing home plans.r >> that is a requirement. >> where they followed. >> according to the report we got from our state facilities they were not followed in this instance and that is why the facility has been terminated from accepting medicare medicaid patients. >> so that's the consequent. >> that is the consequence. >> okay, i wanted to talk toat doctor cadillac about the hospitals. one week after hurricane maria they told the committee staff that most hospitals were damaged and faced major challenges in getting food, water, we talked about that. more than, and then more than aa month after hurricane maria they reported that surgery is being done by cell phone flashlight. there are pictures that show that. i guess it's pretty well documented. and so, what i wanted to know is due hospitals connected to
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the electric grid have g access to full regular power, or is it only being provided intermittently. >> it depends where those hospitals are, there has been issues with reliability, i would have to turn you over to the u.s. army corps of engineers to talk about what specific area. >> when you say all hospitals are connected to the grid, that doesn't mean. >> there's only 60%to of hospitals that are connected to the grid currently, as of today. >> and the others, are they operating. >> they are operating on generators and we are basically working with fema to have an plus one where they have to backup generators so that if they need to switch, if the generator fails they can go immediately to thee next one, and again, the plan is to basically have 911 fema
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generator repair team to come out and fix the primary generator. >> as a consequence of all this, you would say there is now 247 power at what percent of the hospital. >> 60% right now are on the grid which have regular power, and even then there's some reliability issues as it relates to transmission wires and distribution that i have very little understanding of because i did very badly in electrical engineering, but i think the point is there are hospitals out there that are on the grid and even those hospitals have generator backup. >> okay. i wanted to turn for a minute to the virgin islands. i understand hurricane maria tore the roof off of the two largest hospitals in st. croix tand st. thomas. what is hhs doing to ensure americans in the virgin islands are receiving the healthcare they need? >> immediately after those storms passed, both emma and
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maria had effects on both st. thomas and st. john, st. croix, where the hospitals are located and with the passing of those storms, the initial storm, we basically set up a team with temporary shelter and that was replaced with a more capable army support clearing medical station which is a 40io bed many hospital that's their, and now we are in the midst of basically deploying a western n elter assembly so that would allow the physicians and nurses and healthcare practitioners on the virgin islands to go back to work and take care of their patients while the hospitals are being assessed by the army corps of engineers to either be repaired or replaced in the case of st. thomas it will likely need to be replaced. we have provided immediate care, were providing intermediate support and were basically transitioning to a
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capability that would allow the healthcare workers on the virgin islands to go back tork work, and with that, give time to basically repair or replace those hospitals. >> thank you. i yield back. >> thank you. we now recognize mr. collins for five minutes for questions. >> thank you. thank you to all the witnesses for coming. doctor, while we are operating hospitals under generator power and the like, as people are being transitioned out of hospitals, in many cases the residents don't have power at home, and they don't have running water. could you perhaps explain what's going on relative to these patients leaving and how are you and others now dealing with the fact that they are moving into an environment without power and in many cases without running water. >> just to highlight a comment i made earlier, there are six federal medical stations that have been deployed to puerto
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rico. at the presentnto time, to our operational that are being staffed by va workers as well as volunteers, in one case from the hospital association, a great example of combined effort between our federal and volunteer partners that are basically providing those kinds of transition places for people who need additional medical support or care. if they can't go home for whatever reason, we set those and have more imposition as required to do so. >> that's reassuring that you are basically assessing patients one by one to make sure that when they are released they are getting the care they need. >> yes or. >> another question,n, and they are asking for cash payments many cases, the folks
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needing prescriptions don't have that cash. whether the question should go to you or the doctor, how are we handling. >> there's a program called emergency pharmacy assistance program which provides free medications to individuals who can pay for it so that's been invoked so people who don't have cash and need medicine can get it. that's one way. the other way is if they were go to one of our facilities that are co- located in regions of puerto rico, they can get medicines from there as well who provide prescriptions or medications as required. >> that's reassuring. in some cases, someone who's been on prescriptions, or i'm assuming there's some difficulty evenul in the pharmacy contacting the physicians office but i know if i go to fill one and it's
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expired, they say will contact the physician and get back to you, but the because of the lack ofcku. infrastructure, hows that being handled. >> not only medicine but prescriptions are basically being filled out for people who seek them out. they have to basically present themselves to one of our demand teams or military facilities or va facilities, and they will get a prescription if not the medication itself. >> again, i appreciate, you're basically taking what i would call a one by one approach, every situation somewhat different, but i'm getting comfortable that you're taking care of people as best we can given the limited infrastructure and in some cases doing things in an unusual way. >> yes or. >> doctor, the representative has asked me to ask you, on the fda issue related to food and agriculture, what would be your overall assessment and
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are the situations of granting waivers, understanding it's not business as usual at all. >> thank you for the question. we would typically grant waivers if crops that were damaged in hurricane, if the producer was looking to divert crops intended for human consumption into animal feed and we do process those waivers. in terms of what were doing right now, we have already conducted, i believe, 20, not inspections but site visits to various agricultural facilities and food production facilities to help them get back online. we've done this in the past week or so, even as our own employees down there have been devastated by the hurricane, we had about 100 employees on the islands. we've conducted a total of about 36 inspections of various medical product to help them get back into
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production. >> i want to thank you and mr. chairman, i'll yield back, but i guess i need to say, i am really happy to hear of the response that we have in puerto rico given the fact that the island was devastated , it is an island nation, and while it's always easy to criticize w response, what i am hearing is a lot of actions have been taken, one by one to make sure b people are getting the services they need. we can't snap our fingers and rebuild an electric grid overnight, but everything i am hearing, is, and i would disagree with the member that was going to give them a two on a scale of one to ten. i also don't like to give grades but i think that's a bit harsh, considering the devastation that the island withstood, and the fact that we've never seen anything like this before. i want to thank all four witnesses for coming here today, and i'm certainly leaving here today feeling much more comfortable about what is being done to take
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care of the tragedy that did occur in puerto rico. i yield back. >> thank you. we now recognize the german from california. >> thank you. when you get down to the end, a lot of questions have aske been asked already. i'm going to ask an open-ended question from the respective prevention. : : would have mitigated the response to the extent that we had? >> cannot comment that while the three hurricanes, the major ones, harvey and irma and maria, they were very aggressive in deploying our
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assets, people, capabilities, gilogistics . as far forward as we could in the case of puerto rico, putting people in harm's way to be there when things happened . you can never anticipate how things will unfold, particularly florida, if you recall went from the east coast to the west coast, thankfully and that kind of acceleration of the storm before it hit 10. that's a little bit of good luck. you can always count on that but one of the things that comes out of this is the importance for community resilience, individual resilience. those are things that somehow are not necessarily the gentleman from hhs but in the department of homeland security often use october as preparedness month and asked people to see if they have a
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plan, if they have supplies, the necessary things. the things i like that element that individual preparedness, no matter how good we may be, there's going to be a circumstance that we may not be able to get there immediately and you have to buy for yourself and your family in the immediate term . >> the health agencies a including cdc, do you think that put into the content of the outreach that's happening around october, how to be ready from your perspective? >> i'd like to defer to admiral red to talk about cdc but we do participate in these interagency conversations but again, we in just wonder what kind of messaging you need . i think as we look towards the 21st century and my role, preparedness and response, the certain sequences we find ourselves in after 9/11 are different than a. as we find ourselves in when my position was created, 2006 are different today than they were then so i think the thing is that part of it is
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keeping up with rapidly changing environments. >> that's the premise of my question, are we keeping up with it or is there something we need to be doing? >> i'm going to take advantage of an opportunity to point out that the pandemic preparedness act be reauthorized in the spring of 2018 and i believe there should be things that reflect that change threat environment. i think we mentioned the issue about structure of the natural disaster medical system. i called for the idea of a national disaster healthcare system that would be basically built intentionally on what's been proposed with the national trauma system, basically to ensure that we have the capabilities the country needs to face whatever the threats in the future whether they are natural or man-made. >> i think the answer to your question i think is different depending on the horizon. i think certainly since 9/11
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there have been remarkable improvements in our ability to respond in a coordinated, cohesive veway. one comment that i make is that these three different hurricanes were actually very different events that in texas it was really a flooding event, not very much wind damage in the most populated areas. puerto tarico, it was primarily a destructive wind event so the nglesson from that is being adaptable is a critical capability. i think we are continuing to get better at being adaptable to the circumstances that we are confronting. >> i want to thank the witnesses and yield my remaining time to doctor luis . >> i have a few seconds but the idea of peripheral field command posts, with that be better helpful to coordinate with all the stakeholders? >> it is and we have the communications capabilities . it can happen, but it is defined and joined.>> with
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that be a solution? >> in a narrower way, from a surveillance standpoint, having hubs that could report in would be something helpful to understand what the facts on the ground are. >> i'm going to suggest that we start doing that as well and another mention his unnecessary debts, epidemiology is one thing to be killed by a falling branch or drowning from the river, the other thing is to die from not having medication that they could have had if it wasn't for the hurricane so there's a lot of unidentified bodies and a lot of death occurring.we need a better way to count how many are due primarily and secondarily from the hurricane. thank you. >> thank you for yielding back and i recognize the gentleman from texas. >> i think the chair and welcome the chair. as indeed the chairman of the subcommittee.u
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i thank you for allowing me to inform you about membersof the subcommittee. i'mhere to talk about hurricane party. three aspects of hurricane harvey , mental health , and mosquitoes. i moved to .the texas gulf coast in the summer of 1972. at that time you heard the legends of hurricane galveston, worst natural disaster in our country's history, over 6000 lives lost, 8 to 10,000. i would therefore hurricane felicia in 2001. i in 2008. harvey did more damage than those hurricanes combined. hit us twice, hit us once and hit us again. we faced many health challenges. with dioxin, reached out in the river.
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for chemical spills, raw sewage spills, walls of fire ants, massive flood fires that got out of control, flesh eating bacteria took two lives, one at galveston and a firstresponder , my district was affected with heavy, heavy antibiotics. local health became a big issue. i saw this firsthand.i was at a elementary schoolhit by the tornado that held hit the plantation . talk to parents, school kids coming to class. one young man came, very proud. a tornado hit my home, knocked out my window as i was sleeping. i came back and i said man, he's doing great. he said, t.no he's not. he's great at school, it's a great story that i beat the hurricane or tornado but since that hit his house he can't sleep. he called his mom and dad infor
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security and safety because he fears for his life after what happened with hurricane harvey and that's one example of how kids are traumatized by these events and also adults. we went through days and days of. [siren blaring] we probably slept for hours over three days. four daysafter hardy cleared, there was a flash flood . people all around got freaked out hearing those alarms again. the worst is what resource we use and maybe mister gottlieb, what resources are being presented from hurricane harvey, what can be done for these people? >> i'll defer to my colleagues on the panel and in my role as commissioner with respect to what we've been focused on coming out of hurricane harvey in addition to their being some medical
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product facilities in the region, the predominant issue has been related to property destruction and issues related to requests for waivers for divergent of props into animal feed and going forward, we will probably have to take some steps to help with remediation of fields that might have been exposed to heavy metals from the flooding but we are primarily focused on issues related to the crops that were damaged in the aftermath of the hurricane . >> admiral >, do you have any color? >> on the mental health question in particular i think that there are maybe three points. one is understanding, four points. one is that these events are devastating and they have effects on everyone. most of those effects are relatively short-term or most people and i think for people when those effects are not short-term, we need to be able to make sure there is
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availability of services. second point is understanding the magnitude of that, that group of people that need long-termhelp . if i could remember my third point. i think that's it for me is two points. >> this other point quick po which is that we use the public health commission core , behavioral health teams, they been most recently deployed in the virgin de islands but also they provided a hotline to call people who have had, 11,000 calls outo a counselor on the phone to ask about their emotional issues and then find some assistance that way. so there are somecapabilities out there and d we've been working with, again, it's
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dependent on the local authorities to initiate these things but certainly stand ready to assist where it is appropriate . >> you're ready for your third point's actually, a couple more but we're going to talk about mold. we are working closely with the department of health. when there's a flooding event, structures that are flooded will become moldy. we are doing three different things and mold, one is trading of responders, the other is working on commutation materials and the third thing is working with the department of health to investigate the potential for increasing infections due to invasivemold . >> my german also i'll remind everybody it's one thing in texas. ela, i kneeled back. >> thank you gentleman and i now recognize the young lady fromnew york, ms. hart, five minutes for questions . >> i'd also like to remind everyone that we are talking about territories that are in tropical climates and that
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our island territories. out here we talk about puerto rico as a model it. there's also three islands with respect to the us virgin islands and that is st. john's, st. thomas and st. croix. i don't want to see this as a monolith because each of these islands have their own identity, their own inhabitants and i'm not hearing enough of a deep enough dive into what is happening with the inhabitants of all of these territories. because it's not one singular event. it's an event that hit three separate geographic territories. i'm putting that out there because i'm going to want to hear more about what has happened in terms of response to those territories. we are not hearing at all about how the people of st. john are receiving
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healthcare, we're not hearing that information and that is just as important. i'd like to start my question about the evacuation process . what assistance was provided to prepare and implement an wa adequate and efficient evacuation plan for those whose health is compromised and what their coordination assistance is provided to the local health department and the weight of the hurricane to track the relief that was sent to other islands in the mainland? >> i can probably address that in deference to your question, i would highlight the map we provided which identifies where hhs is providing augmentation support. st. john's as well pas st. croix and the virgin islands. we had a presence on that island as well. to your point about evacuation, from the complexity of this event and irma struck st. thomas first
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for which we were doing some unprecedented things using cms is power database we were able to send out search teams and identify dialysis patients which we recovered 20 of them and evacuated them to relative safety in puerto rico until maria hit at which point in time we evacuated literally the day before, the day of landfall and evacuated ngthe stations to miami to my medical shelter there where we could ensure that they were being cared for. in the cases of other patients who were evacuated from the virgin islands, they were evacuated to atlanta. again, receiving care through local resources and so throughout me and here is not only do we evacuate those dialysis patients but a
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family member so they would have someone to assist them along the way. at the present time there's only been a handful of evacuations off the island from the mainland. there were two pediatric patients and intensive care patients evacuated from san juan, miami soon after landfall. but what we tried to do is maintain a focus on puerto rico because they need to be closer to family and the support units so the way we address the problem in puerto rico is we created the seven regional hubs, hospitals that we augmented with our disaster medicalassistance teams . we took the benefit of a level i trauma center in san juan. we had the eastern hub, receiving hospital for high acuity or intensive care patients and the uss comfort as the other hub, western called and a global hub that we could run basically from the top of a receiver down to
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pensce on their acuity as required. and then and able to use dod assets both ground ambulances and medevac dust off helicopters to provide response on the island and then using naval medical assets, rotary wing and fixed wing assets -- >> if there's a document that you have that outlines that, make that available to the committee. i wanted to talk about the public health challenges of cthese island territories. the islands will need the assistance of the federal government in the weeks, months and years to come. what is the agencies position of the medicaid as it relates to the virgin islands with its already limited resources and do you support a full federal contribution as the federal government did for katrina?
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>> i'll defer to miss france. >> thank you for that question. that is certainly something we are looking at and we are trying to see whether we would have the flexibility to do that but that's a statutory. >> i'm asking about your recommendation, right now you have these islands, all right? island territories where in one case the us virgin islands, their major employment is throughtourism . right? no one's working. so are we requiring that government to come up to come up with a match or are we going to suspend itinto a full federal contribution as we did for katrina? on the mainland . >> we are pursuing that, working with the office of managementand budget to pursue that . i yield back mister chairman. >> thank you, now
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recognizing the gentleman from georgia, mister carter. >> thank you mister chairman, i appreciate your presence. that's ms. brandt, can you help me here. i know the situation exists with the nursing own situation in florida, are you going to require nursing homes to have generators, is that going to be a requirement and can you briefly tell me how that's going to work? >> we have an emergency preparedness rule finalized last year that is going to be starting again next month . it requires generators, it requires emergency preparedness plans and requires training on a continual basis . >> professional career as a nursing home consultants and i can tell you they are placed for trying to stay solvent as it is. is there going to be any kind
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of hope for them or is this just another government mandate? >> that is something we are looking at but i can't speak this typically is that at this time iq. there was an article in the wall street journal about the comfort, the naval ships that was a medical ship and how it was off the coast of puerto rico, that it wasn't being utilized and i wanted to get your input on how we could do a better job in the future of making sure, from what i understand it's a 250 bed hospital on the water but there's only 150 beds being utilized at one time what can we do to make that better. it's costing us $180,000 a day to have it there and those people desperately in puerto rico need help . >> and again, i allude to miss clark's question, part of the plan was use the
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comfort as a capability to deal with high acuity patients. particularly in circumstances where hospitals on generators would fail, where we would need to urgently transfer patients somewhere and so we were basically using the 50 bed icu on the boat. >> we understand and ho appreciate that but it seems like we could have made better use of it. have you learned anything, is there anything we can do differently to make it more accessible in the future? >> we are looking how we can utilize it more as a stationary platform. and make it more accessible and that's been an ongoing conversation with the department of rico to assess h how we can use that to their needs. >> thank you. doctor mr. gottlieb, it's my understanding that the fda can declare on the shortage
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list medications that are not available and that they can be compounded, is that true? they can be compounded by pharmacies if there put on the shortage list? >> we don't typically look at the opportunity to compound as an alternative solution for shortages. our drug shortage staff work to help get the approved product back in supply and might look to outsource the same product from overseas manufacturing facilities. it might be inspected by fda. it is in the case in certain situations, you might see track practitioners go to compounding facilities within the confines of the statute. >> so you're actually increasing access to alternative medications, is that what you are trying to do? >> thanks to some of the new authority that congress gave us and our ability to identify shortages further
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out from the actual, we've been taking steps to mitigate the shortages that have occurred but also situations where we see the potential for products to take into shortage. we're looking out one or two months from what we think could potentially happen if production doesn't resume and taking steps to for example move temporarily certain manufacturing outlets that might be damaged or not up to full production in other markets that could help supply. >> i would ask you as you continue on your process for the memorandum of understanding, dealing with om compounded medications that you would take into consideration natural disasters and that there would be exceptions put in where compounding pharmacies could be utilized where they could get those medications to those patients and natural disasters such as s. >> there might be something
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more appropriately addressed onbut certainly i can go to work your honor. >> i will be happy to work on that in the statute. i will ask you dr. gottlieb, is the cdcsupporting that . >> i would assert at my colleagues, >> there is no vaccine for leptospirosis. it's very treatable, it works better for diseases identified so earlier treatment is more extensive. >> is that being supplied really. >> the antibiotics, they're not anything special so tetracyclines. >> that's not available as much as it ought to be. >> it depends on which. >> dr. gottlieb will attest, unless you're getting it for fish tanks. >> nevertheless. i'mserious. >> nevertheless it's a problem but thank youvery
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much and thank all of you again and i yield back . >> . >> now recognize the gentleman from new york. five minutes for questioning. >> thank you mister chairman, and as a writer at the subcommittee, reports the standing committee, i've made clean drinking water a major effort to focus that i'm very appreciative that the committee has responded to. we've recently reported a bill from subcommittee and the standing committee so therefore, i want to address that concern, clean drinking water. run a report about the lack of drinking water in puerto rico. unfortunately neither feeling the epa today so doctor red i'm hoping that you might be able to share some insight into the water situation in order to rico and the virgin islands. the recent news reports have as stated that roughly 1/3 of puerto rico is now reliable access to potable water at
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home. because of this, we have heard reports of people drinking and bathing, and streams in puerto rico. last tuesday, puerto rico's date pdb outages carmen decided announced that there have been 74 cases of leptospirosis. reported on the island by this month. puerto rico usually sees only 60 cases of this disease. as i've been informed in a given year. some reports have connected this out in public use of contaminated water sources so i asked, can you tell us about this whole concern about leptospirosis and what are its symptoms? >> certainly, leptospirosis is a bacterial infection, it's acquired as you described by drinking or being exposed to water that's contaminated with those bacteria. they infect many species of animals and animal urine is
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the vehicle for transmission of the disease, so situations where there's a shortage of potable water or exposure to waters that are contaminated with the bacteria are the settings for exposure. we are working closely with the department of health and puerto rico to confirm or to determine whether those cases are cases, we have specimens in the laboratory cdc right now doing those tests area there is, we are aware of one confirmed case that was diagnosed at a patient in the va so how large this outbreak actually is, if it's an outbreak is something that remains to be determined . the best way to control the outbreak is to prevent exposure to contaminated water and that is an issue that you started with as wider availability of potable water and earlytreatment for people that have symptoms .
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of either weakness exposure to those things and in the later stages, more characteristic is the jaundice, yellowing of the skin because of liver damage. and for the question about the extent of the water supply system, i might refer to doctor, mr. kadlec on what the situation is. >> i can give you basically down that we've been following 25 out all the hundred 50 public drinking water facilities are out of service. so that's an issue of again prioritization in terms of real education but definitely also is can out of the 51 wastewater facilities are out of service so it gives you a rough estimate of what the situation for water is on the, but if that's being followed by the us army corps of engineers. >> and back to the disease itself, is it normally
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treatable? >> it is treatable, it does have a significant mortality rate for severe cases, 5 to 15 percent fatality so it's a serious disease that we need to take steps to try to prevent and recognize treatment on. >> and how to critical is it that patients be treated? in a matter of days or hours? >> the sooner treatments, like many bacterial infections, the sooner treatment can be started the more effective it is so early recognition is very important and some of that have to do with access to medical care. >> are there any other diseases associated with drinking and bathing in rivers and streams, particularly after these heavy rains and flooding. >> are there other health concerns? >> there are so the conditions that had cause gastrointestinal illness are
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going to be more common in floodwaters wastewater that have sewage in it. >> there are also skin infections that could be more common when people become exposed to that. so really, it's a variety of diseases as well as something that's been alluded to earlier, the ability to wash your hands, do things that will have many other additional effects. >> i yield back. >> thank you gentleman and i appreciate everybody bearing with me. i'm going to reserve to go to the end, i now recognize mister bill araki is from florida. >> thank you mr. chair. and thank you for allowing me to speak on the subcommittee. secretary, to the hospital preparedness program currently allow space to use grant funds to help defray costs associated with
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procurement and maintenance of generators for assisted living facilities, scaled nursing facilities to support the development as a statement of healthcare coalitions? >> the way the grants are structured it's exclusively for healthcare facilities and for coalitions thereof.as so as part of the plan of a coalition, that could be configured as part of it. we don't dictate that as being part of it. we're looking to identify how w these hospitals and hospital systems can become more resilient but previous your question if i make it back to you on that ican give you a more fulsome follow-up . >> that's very important. see whether it's permissible because again in our area there are, what nursing facilities but also our labs did not have generators. that's a priority.
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>> i'll get back to you. >> maybe you have 10 patients or less, we've got to make sure they have the generators, the backup. ms. brandt, last friday the commission sent a bipartisan letter to the owner of the rehabilitation center at hollywood hills in florida, raising concerns again of tthe nursing home in florida. i'm sure you're aware of this, 14 residents eventually died after the facility lost air-conditioning in the wake of the hurricane. there was apparently a fully functional hospital across the street, unbelievable and according to the florida agency for healthcare administration, the facility administrator and medical professionals didn't know to call 911 and emergency, i can't understand this. what's wrong with these people? how could the nursing home the so unprepared for a medical emergency for 14 residents lost their lives,
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especially when there's a hospital across the street, can you answer that question please? >> thank you for the question and as you are aware hollywood hills had been terminated from dissipation in the medicare medicaid program. we make patients safety our number one priority for the residents of eall our medicare facilities and this was a complete management failure at hollywood hills which is why they were terminated. they did not meet their condition of participation for keepingthe temperature at a reasonable level, did not cry provide adequate care to the patients, there was a hospital across the street . so they had several levels of what we call immediate jeopardy for patients which is why they were terminated. >> who's ultimately responsible for their safety? >> as the chairman said, the facility had the
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responsibility and the management has the responsibility to ensure they are meeting preparedness requirements, that they are providing adequate care and we survey and hold the facilities accountable to those requirements. >> . >> that very important in the accountability, obviously the appropriation is so important. what can cns do to ensure a tragedy like this never happens again? >> one of the things that we've done as i mentioned in the written testimony is that we instituted a number of preparedness rules which requires that facilities emergency preparedness plans, that they drain on the plan and make sure all employees are aware that they have adequate backup in place to allow, you mentioned in the discussion, generators and other things to ensure that they have adequate power supplies to ensure that patient care can be provided that they have a plan for where the patients can go if it cannot be provided. >> what about puerto rico? i understand there are nursing homes operated by
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air-conditioning. >> very unsafe, who's responsible for this, who's supervising this.cns, do the checks and obviously it's unacceptable. but can you respond to that? >> in situations like puerto rico where you have almost unheard of positions of no water, no power, you have really no ability to provide, we work with all our partners, doctor mr. kadlec as well as the fema teams and everyone on nethe ground. federal and state but also the territory officials in puerto rico to pull together, get patients to a safe place. if they don't have the ability to anprovide care, we worktogether to get them transported to a safer place . to the evacuees that mr. kadlec was talking about from the virgin islands. >>i appreciate it and i yield back . >> we now recognize the mister green, generally from texas for five minutes. >> thank you mister chairman and coming from the houston
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area, a very urban area, i heard today that we had our second bacteria.from and in galveston county, we had one in the south of us where i'm aat but also to the north we had a 77-year-old lady and congress imposed the pass caaway. we have great medical facilities and that gentleman is from the dmv which is the center for infectious disease. at that been prevalent in artery go or virgin islands because i know we have a lot of standing water or at least we did have and my guess is it's cdc. >> i'm not aware of the case that has occurred in the other hurricane affected areas. the condition you're describing is pretty infrequent in the us. that's 700 cases per year the last four or five years, that
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disease occurred so it's not common but exposure to floodwaters is a risk factor for that condition. >> thank you. hurricane harvey created so many serious environmental and public health issues including evidence of compromise on site and toxic spills, chemical fires and high levels of air pollution. epa conferred in the aftermath of hurricane harvey, we had a location called the pitts and harris county now in that district but it was in my district, it wasn't in his district so we changed those but our c constituents will contact all three of us . in alice's town, there were concentrations of 2000 times higher than the level the epa required cleanup. and the epa administrator was there literally two weeks ago to visit that site and the
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decision had been made to permanent cleanup that facility in east harris county so i was glad of that. what are the types of risks associated with substances such as a dioxin facility. just don't there in the 16th by the paper mill, we have responsible parties but in both the state of texas, the harris county and city of baytown that's there that signs up in both english, spanish and vietnamese not to eat the pcrabs and food but when i go there, you can't find anybody that doesn't have a fishing pole. the signs say if you're an expectant mother or child, you should eat these crabs but a lot of people still do. what are the types of risks associated with that other than the problems with eating it? >> i'd like to respond to that question, i don't want to say anything incorrect here and i think the level
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that we areseeing in that setting . >> okay. like i said, the decision has been made to clean it up but my concern is a lot of my constituents to go out there and fish and crab and i keep explaining to them you need to pay attention to those signs. according to the houston department there were millions of contaminants in floodwaters over most of the city. heavy metals in the floodwaters summit were also found. following hurricane harvey, what role can the cdc play in warning communities of waterbornerisk ? >> in general in that part of the response we were working in support of epa. on the kinds of things we would do would be to make the warnings that you've described, make sure people know those things so that the public health communications because of the flooding. >> additionally, not just
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from an industry but about 50 drinking water systems are shut down following hurricane harvey and more than 166 tons issued boil water advisories. this is an issue also we are seeing in puerto rico where they are issuing boil water notices. some people are not able to boil the water. given the boiling water may not be an available option, what are some of the hazards of drinking potentially contaminated drinking water without boiling it and how does the cdc communicate these hazards? we may be over it in southeast texas i hope in the virgin islands and puerto rico? >> the hazards that one would be exposed to drinking water that would be contaminated with sewage would be the
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things we talked about before. gastrointestinal illnesses, the inability to do and hygiene and a lot of other diseases and if there's superfund site contamination, exposure to some of the materials in those waters, i think this is just to bring back one other point. as one of f the reasons having the public health laboratory in puerto rico online is so important so that testing can be done and when water is safe to drink it will be easier to confirm when that testing is available . >> iq, and all out of time but every year the, every seven or eight years we get a tropical storm so hopefully it will be rmthat long time but are we learning any lessons from hurricane harvey both in southeast texas or louisiana that could be applied in or to rico, virgin islands or hopefully where learning to get better prepared or our water system is when they shut down, that's really a human need that we have to have.
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mr. kadlec, i know you mentioned that. >> i appreciate that. and thank you. >> atthat being said, i recognize myself for five questions. >> and this will be the end so you are almost done's dr. gottlieb. >> black mold, all of the areas we talked about, everybody knows there's going to be mold issues but here's one of the issues i'm not sure most americans know, what are the symptoms because obviously if you see it, you're going to do something about it or try to do something but often it's a hidden concern. so what should people be on the lookout for? >> i defer to cdc. >> you're absolutely correct, herman that flooding meets the mold contamination. the, there are two different hazards from exposure to mold, one is the worsening of allergic conditions and that
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can be quite serious in the case of somebody that has asthma that's sensitive to mold. the other is for particularly people who have we continue systems, infections from mold that also can bevery serious . >> how are they going to know. >> i recognize but what are they going to be seeing? >> when building materials have been damaged, i think there's, it can, if mold can grow, it will so it's a question of remediation. in other words, for forest surfaces, removing those services and rebuilding services for us, cleaning them up. guidance in those areas is what cec has been providing, working with the texas department of health . >> i guess i'm concerned if you don't see it, you don't know if there and i know you're going to start having
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some wrestling to figure out asthma but what if you don't know about. >> is that one of the first way you tell is chest congestion? >> i think for areas that have floodwaters, you can tell where that floodwater has been. >>. >> all right. mr. kadlec. in a month, i think you have any hospitals in puerto rico that are not in executive information? >> if i remember correctly, there were about three. there are some that have been . >> physical damage to the point where they cannot. >> and the ones that are open and refusing to accept petitions? >> i don't know what is the we have circumstance where the patients, i can't give you information answer. >> we talked about dialysis before, any other specialized treatments?
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>> dialysis is available through the 46 of the 40 clinics on the island . depending on the hospital, there may be services that are not available like it give you an affirmative. >> let me ask you this because i read report somewhere that dialysis was available were coming shortly treatment from what normally would be, is that still indication. >> we are looking to actually work that problem out in terms of lowering the stress on some of those clinics. we see fewer patients or refer patients to places that have more functionality. >> that brings up the comfort . the united states navy ship comfort, is sitting out there , we had a lot of patients. this is a question my probably not do this earlier, what is ithe approval process or the admission process to get on board to be approved for the comfort? >> the was kind, it doesn't
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have based on the hurricane came through, these facilities were assigned on the east side, referrals of any kind of iq patients in intensive care patients that need to be made responsible around the east side of the island. >> that's a level i trauma center and we will be done through ground or waiting transportation. the determination of where those patients would be moved , i'm saying this to the comfort, that's based on decisions like central mexico that would review and talk to the doctors at the local hospitals to say what is this patient suffering from, what kind ofcare they need, what kind of services do they need . based on that, it would be transferred. >> one of my concerns, i recognize some might argue that we got an asset down there were not using.
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trinity, there's a long-term concern that you had, both puerto rico and otherwise, what's your biggest concern that the fda may behind. >> i think it's a long-term concern right now from a public health standpoint is that we may face charges adding into the first quarter, we're going to do everything we can to have them off.ea my biggest long-term concern for the island of puerto rico is that we don't do our job in helping these facilities stand back up in a timely fashion, we can start to see some of the production about and that would the strain on the puerto rican economy. that's solidarity with the people of puerto rico to keep production and it's an important part of the island. >> i appreciate that. i see that my time is an ideal back . >> just following up on that. also, it would take away jobs from the island. >> about 90,000 people directly employed by le
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industry, these are very high pain manufacturing jobs relative to auto manufacturing. it's an important part depending on estimates, 23 percent of the gdp of puerto rico, an important part of the island. >> i was in conclusion to thank all the witnesses and numbers that participated in today's hearing. i remind members they have 10 business days. i asked that the witnesses all agree to respond promptly to the questions they may receive after the hearing. i have to say i learned a lot .you all for participating, you all contributed greatly er and i think i have a better understanding. i look forward and maybe you can suggest where we can go live look forward at some point to the committee and subcommittee perhaps visiting. the islands to see what we got or perhaps as well the other areas that have been infected by the hurricanes. with that being said, it is adjourned.
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>>. >> coming up saturday night, remarks from hillary clinton at the human rights campaign dinner in washington dc. she will be joined by amazon ceo jeff basis and for the team gain. live coverage starts at 7 pm eastern on c-span. this weekend on tv on c-span2, book publishers 70 anniversary party in washington dc.
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>> sunday at 8 pm, news correspondent katy perry reflects on the trump campaign and the 2015 presidential election in her book unbelievable, why friend rosie for the craziest campaign in american history. >> is no secret politicians like reporters generally. nixon had brought relationship with his press corps. the legendary stories about ron ziegler. his press person, and getting into it with reporters. what was unusual about this was the very public nature of it, the way he would go after reporters , myself included and have the crowd, encouraged the crowd to essentially turn on us and us . >> and it 9 pm eastern on afterwords, the foremost of face the nation bob schaffer
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on the impact of changing technology on journalism in his book overload: finding the truth in today's deluge of news. mister schafer is interviewed by susan glasser. >> the first thing we have to keep doing it doing what we're doing and that's trying to sort out the true from the false and that's an overwhelming job now is the bigger responsibility than we've ever had because we are dealing with so much more information. we now have access to more information than people in the history of the world. but we're running short on curators right now. we are getting so much information that we really can't process it. >> for more of this weekend's schedule, go to booktv.org. this week on two and eight. >> their shopping and jostling. and i was behind him and it
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kind of intensified and it looked like he was going to fall to the ground. it was at the time a 74-year-old man i did what any human being would do when you see a 74-year-old man on the verge of falling to the ground, i grabbed him by the arm to make sure he didn't fall but also there's been a large, i don't know how many but i was fearful of being separated from them so i took his arm and that's when they all turned on me. somebody pulled my hair, body slammed me from the other direction. >> professor allison stinger discusses a violent protest on the campus last march following a schedule lecture by a political scientist charles murphy. watch allison steiner on trendlines q&a. >> us defense secretary james madison made comments about us diplomacy with north
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korea. we took a visit to the korean email is rise zone which is the border zone between north and south korea. territory mass was meeting with south korean leaders a week ahead of schedule trip to asia. this is under 10 minutes. >>. >> yes. yes. you have to go back behind the white line. behind the line. >>. >> man, for the official photographer translate.
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>> this area we are standing in now, that was not only a site of intense and bloodied battles for the us marine corps but also on the day 1953 27th of july, it was a historical event where the armistice agreement was signed. >>. >>. >>. [speaking chinese] this place is historical significance. even more profound when you consider the fact that here was the place where the north silo was held to maintain paris peace between the two
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koreas as well as armistice talks ongoing. at this point, there is no dialogue that continues between korea. >> . >>. >>. [speaking chinese] and myself and secretary mathis stand here to show that the us alliance is close and well cooperated as well as completely aligned in our stance. [speaking chinese]
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>> we hereby also affirmed that although north korea continues to develop nuclear weapons and missiles, these are weapons that should never be used, should they ever use it, they will be faced with the strong might of their combined us forces and they will be met with the proportional and for response. >> . >>. [speaking chinese] we also strongly implore that north korea stop its reckless provocation and come out toward the path of peace and dialogue . [speaking chinese] and the minister of national defense of north korea and you sign state secretary, we together will continue to defend these
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through drawing will and strong might. >> thank you. >> thank you mister son and i'm here today to reaffirm the united states ironclad commitment to the south korean people. >> this visit to this the militarized zone portrays a very strong terms the difference we see between two nations. >>. >> to the south lies a vibrant country, a vibrant economy, a free country and
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it's underpinned by peaceloving members of a free society . [speaking korean] behind me to the north and oppressive regime that shackles its people, denying their freedom, welfare and human dignity in pursuit of nuclear weapons and the meansof delivery in order to threaten others with catastrophe . [speaking korean] north
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korean provocations continue to threaten regional and world peace and despite the unanimous condemnation by the unitednations security council, they still proceed . [speaking korean] and as the us secretary of state tillerson has made clear our goal is not war but the denuclearization of the korean peninsula. [speaking korean] minister son, two days ago at the
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republican philippines we made clear our mutual commitment to a diplomatic solution to address north koreas reckless outlaw behavior. [speaking korean] and together we noted that we are serious about solving this problem. [speaking korean] and we stand shoulder to shoulder with you, your shoulder people and your soldiers and confronting the threats posed by the kim jong un regime. >>. [speaking korean] and i look
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forward to our discussion tomorrow at the security council meeting where we will discuss ways to further strengthen iraqi us alliance. >>. [speaking korean] >> this is an alliance of more than 60 years and one that we both know is built on trust . >> . [speaking korean] >> it is an alliance designed to ensure be and stability along the korean peninsula and the strongest military defense of our shared democratic values. >>. [speaking korean] thank you.
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[inaudible conversation] on monday, testimony from defense secretary james mattis and secretary of state rex tillerson on military authorization powers. speaking before the senate relations committee, gets underway at 5 pm eastern on c-span and watch it online at c-span.org or listen with the free c-span radio app. >>

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